AN EVALUATION OF INSITE

During the last decade, Vancouver has been the national epicentre for
drug-related harm. Particularly within the Downtown Eastside (DTES),
illicit injection drug use has led to epidemics of overdose-related
deaths and infectious diseases such as HIV and hepatitis C. The DTES
has an estimated number of 1,400 to 1,900 HIV-positive residents --
approximately one-tenth of its total population. This costs the
Canadian health care system roughly $320,000 for each person infected.

For years groups in the affected community, such as the Vancouver
Area Network of Drug Users, have been advocating for a medically
supervised safe injection clinic.

In September 2003, amidst much controversy and debate, North
America's first safe injection site was opened by the Vancouver
Coastal Health Authority on East Hastings Street. Insite was opened
as part of the arm reduction branch of Vancouver's Four Pillar Drug
policy, with the other branches being enforcement, education, and treatment.

Health Canada granted VCH a three-year operater exemption under
section 56 of the Controlled Drugs and Substances Act, so that they
could operate legally.

During these three years an external scientific evaluation of its
impact was conducted.

When the Conservative party won the election in the spring of 2006,
controversy erupted again over the fate of Insite. The federal
exemption was due to expire on the 12th of September and despite the
positive impact of the site reported by renowned medical journals,
the federal government was reluctant to extend the exemption due to
"inconclusive scientific evidence." After much public pressure,
however, the exemption was extended to December 2007.

With only 11 months before we reach another critical crossroad,
Canadians must carefully evaluate the impacts that Insite has had
thus far. Although the federal government claims that there is
insufficient evidence to support extending the site's exemption,
there are three people whose work with the site in the past three
years offers compelling reasons why Insite should remain open.

Jeff West: Vancouver Costal Health

Since graduating from UBC, and then studying for a time in India,
Jeff West has been working with the people of DTES. Often found
standing at the door of the East Hastings facility greeting people
and chatting with two or three of the site's users, the Insite
coordinator seems to know everyone by name. He knows the story behind
many of the faces as well. "Almost everyone I know here has some
history of trauma," he said. "The vast majority of these folks are
self medicating for physical, emotional, [and psychological] pain.
There are other things that people are not grappling with, and [a]
drug is a substitution for that."

Each day an average of 607 people visit the facility. "The population
we want to attract here," says West, "is the people most at risk of
unsafely overdosing or contracting blood diseases. The stereotypical
person I want to attract is the homeless person who buys his drug,
goes behind the dumpster, picks up a needle off the ground, fills it
with puddle water, and injects his drugs like that. That is what
people do. How can you not get an infection?" Under the exemption,
addicts could inject pre-obtained illegal drugs such as heroin,
cocaine, and morphine at Insite. The facility provides free clean
needles for the 12 injection stalls, and nurses to assist when users overdose.

West explains that he and his staff do much more than just ensuring
safer injection practices. "Ultimately, I see this site as a health
clinic which focuses on a very sick population that isn't accessing
the public health care system at all." The site's community
transitional care team has been cooperating with hospitals and health
care clinics to help addicts complete their course of antibiotics for
serious heart and bone infections. They often do not receive
much-needed treatment because homelessness, incarceration, and
illness interrupt regular hospital visits.

The facility also has a referral service for those seeking
rehabilitation programs, housing, or health advice.

In 2004, 40 per cent of these referrals were for various forms of
addiction treatment. West emphasises that the ultimate goal of Insite
is to lead people to the road for treatment. "I'm as much abstinence
based as the most ideological abstinence person.

Our goal is to get people from Insite to detox, and ultimately to
abstinence. But people have to be alive to get to detox."

In terms of Vancouver's Four Pillar Drug Strategy, West doesn't
believe that harm reduction is a pillar in itself.

Rather, he sees it as a philosophy from which the other pillars such
as treatment are acted upon. "People think of harm reduction as some
kind of separate thing, I see it as attached and part of the
continuum. The first step in treatment is a place like this, where
you can identify these folks, build relationships with them, and
connect them to the health care system."

Inspector Scott Thompson: Vancouver Police Department

Inspector Scott Thompson, presently the drug policy coordinator of
the VPD, notes that there initially was some controversy within the
department about supporting the Four Pillars and the safe injection
site. While the department is supportive of a public health objective
that would reduce overdose death and the transmission of fatal
diseases, some members have problems with the site from a
philosophical perspective. "Are we perpetuating the cycle of drug use
and abuse? Are we really helping these people?" he summerises.

According to Thompson, the department eventually agreed to support
Insite and the Four Pillars because they realised that harm reduction
may be the best way to deal with this issue. "The traditional
policing approach is to arrest a person X number of times, but we
realise that we can't arrest ourselves out of this problem.

So why don't we give this a chance to see if it is in fact the best
model?" Contrary to some initial fears that the police would be
arresting addicts for possession at the entrance of Insite, Thompson
reveals that the department isn't really looking to incarcerate
people just for possession. "For a number of years we did not charge
for possession in that area, but we still maintain our enforcement on
trafficking." He believes that trafficking is more of the criminal
issue that has to be dealt with.

One of the apprehensions people have about the opening of an
injection site is that it will draw addicts and drug traffickers from
other places to Vancouver. Thompson says, however, that this "honey
pot effect" has not been proven to be the case. "Since the opening of
the injection site, there has not been an increase in drug
trafficking or the open drug market.

People who use it are the local population, people who actually live there."

Thompson feels it is important to allow Insite to stay open for a
longer period of time to properly assess its effect. "It makes great
sense to support [Insite] for another couple of years to see if in
fact this is the best model.

If you're going to have an impact [on HIV transmission rates] you
need to do longitudinal studies.

Right now you don't have that much data to look at." However, he is
adamant that if Insite is to work as well as the models in Europe,
the other Four Pillars of Prevention -- enforcement and treatment --
must be up to par. "The injection site is one very small component of
an overall approach which would include on-demand treatment, a very
robust enforcement arm, and a very robust prevention system. Look at
the European models: literally, if you are in an injection site, and
want treatment, you've got it. They have made huge investments all
across the board.

That is not the case in Vancouver and we are going to see these
issues become more acute as time goes on. It's a question of how much
are we prepared to invest."

Dr. Thomas Kerr: B.C. Center for Excellence in HIV/AIDS

Dr. Thomas Kerr is a research associate with the B.C. Center for
Excellence in HIV/AIDS and a co-principal investigator of the
Scientific Evaluation of the Supervised Injection Project. In
November, Dr. Kerr and three other scientists from the Center wrote a
report summarising the findings from the three-year scientific
evaluation of Insite. The article reports the following:

* About 7,410 individuals use Insite. The usage indicates that the
project is successful in attracting its target users: those prone to
overdose, likely to be HIV-positive, and likely to inject publicly.

* Public drug use, publicly discarded syringes, and syringe sharing
has greatly decreased since the opening of the site.

* Use of Insite is associated with more rapid entry into
detoxification programs and increased uptake of other addiction
treatment amongst injection drug users.

* The facility has not caused an increase in drug dealing in the
immediate area. The crime rate is stable in the neighbourhood. There
is no evidence that the provision of an injection site has resulted
in increased rates of relapse into injection drug use or the number
of new initiates.

* There has been no overdose-related deaths at Insite since its opening.

Sixty per cent of overdoses within Insite were successfully managed
by facility staff without an ambulance call.

When Dr. Kerr reported these findings at the International Aids
Conference in Toronto last year, the response was "immensely
positive." "When we gave the talk reporting on the results of the
three-year evaluation, we got a standing ovation," he said. "A number
of policy makers and politicians publicly made comments that this was
an important innovation, something that should continue to be
supported and evaluated."

He feels that any opposition to the site that has been stated thus
far "reflects a poor understanding of science." The scientists at the
B.C. Center for Excellence in HIV/AIDS have published 15 studies
within the three years Insite has been operating in journals around
the world such as The Lancet, The New England Medical Journal, and
The Canadian Medical Association Journal. "The fact that we have been
published by some of the top medical journals in the world shows that
the scientific community supports the credibility of these studies," said Kerr.

Kerr agrees that although Insite does not necessarily deal with the
root of the addiction problem, he asserts that as a tool for harm
reduction it is a necessity. "In Switzerland, which has a much more
comprehensive addiction treatment than we do here, they have shown
that only about 15 to 20 per cent active drug users are engaged in
treatment at any time. Meanwhile what will you do about the other 80
per cent who may be dying and transmitting diseases?

The reality is, even if we invested very heavily in things like
addiction treatment, which we certainly do need more of, the research
shows that the problem would never be completely eradicated. There
will be people who will continue to engage in illicit drug use, and
you need to do something to reduce the harm associated with that behaviour."

Despite their different backgrounds and roles, West, Thompson, and
Kerr concur that while harm reduction, as implanted by Insite, has
had positive effects on the community and the drug user population,
and for any long-term impact to be made, the other three pillars of
the Drug Policy must also be established. According to a recent
report on CBC Radio One, federal Liberal leader Stephen Dion agrees,
and further, said that he could not understand why the incumbent
government has not extended Insite's term. Intertwined with the fate
of Insite is the future of Canada's public health programs for
combating addictions. Will Insite become a model for other harm
reduction facilities to be built throughout Canada? Ironically, at
this crucial time when both proponents and opponents alike are
demanding more research to be done, the government has cut all
funding for further research.

With no further funding and an unsupportive government, the fate of
Insite remains an uncertainty until December 2007.